Abstract
Anabolic-androgenic steroid (AAS) use is prevalent among noncompetitive bodybuilders, with potential severe vascular complications. While thrombotic events have been reported with AAS use, bilateral acute limb ischemia (ALI) requiring amputation is rare. We present a case of bilateral limb ischemia, in a young adult who use AAS. Our patient is a 40-year-old male, a bodybuilder with a 4-year history of cyclic AAS use, who presented with bilateral leg pain and burning sensations from the knees to the feet. CT angiography revealed multiple embolic occlusions in both lower extremities, with no other identifiable risk factors for ALI. Management included intravenous heparin therapy and 3 attempts at right leg revascularization through percutaneous angioplasty, mechanical thrombectomy, and pharmacologic thrombolysis. After failed revascularization and subsequent rhabdomyolysis, right below-knee amputation was required. Amputation was successful, and the patient underwent rehabilitation with no complications. This case highlights AAS use as a potential cause of severe vascular complications in young patients. When traditional risk factors for ALI are absent, clinicians should screen for the use of AAS. Early recognition and intervention may prevent limb loss in this population.
Introduction
Excessively high levels of anabolic-androgenic steroids (AAS) can enhance muscle growth, boost lean body mass, and amplify strength when combined with strength training.1,2 This has led to widespread use among elite athletes and professional bodybuilders.3,4
Today, the majority of AAS users are noncompetitive, middle-aged men engaged in weightlifting and bodybuilding for strength and appearance enhancement. 5 Approximately 30% of AAS users develop dependence, characterized by chronic use despite adverse health effects. 6 In the United States, it is estimated that over 1 million men have experienced androgenic steroid dependence. 7
This article presents a rare case of bilateral limb ischemia in a middle-aged male with a 4-year history of AAS use. Additionally, we review the literature on similar cases linking AAS use with acute limb ischemia (ALI).
Case Presentation
A 40-year-old male with past medical history of chronic hepatitis C presented with a 1-week history of bilateral leg pain described as a burning sensation from the knees to the feet. The pain worsened with walking and improved at rest, significantly affecting his ability to work in construction. Despite taking ibuprofen at home, the pain persisted, prompting him to seek medical attention.
The patient had a history of taking anabolic steroids in 6-week cycles for bodybuilding purposes over 4 years, with Testosterone Enanthate being the most frequently used. His history was also notable for smoking 1 pack daily since age 19. There is no history of hypertension, diabetes mellitus, peripheral vascular disease, or heart disease. Family history is negative for autoimmune diseases, coronary artery disease, clotting events, or lipid disorders.
On examination, both feet were pale, cool to the touch, and exhibited paresthesia. The dorsalis pedis artery in the right foot and the posterior tibial artery in the left foot were neither palpable nor detectable by Doppler ultrasound. Blood pressure was 154/96 mmHg, temperature 98°F, respiratory rate 20, pulse 90, and oxygen saturation 98%.
Initial laboratory testing revealed an elevated hemoglobin level of 20 g/dL and a white blood cell count of 9.4 × 109/L, but platelet count, creatine kinase (CK), CK-MB, and troponin levels were normal. A comprehensive panel assessing coagulation, lipids, C-reactive protein, serum erythropoietin (7.6 mIU/mL), and autoantibodies (anticardiolipin, beta-2 glycoprotein 1, and antinuclear antibodies) was unremarkable. Factor V Leiden mutation and protein C/S deficiencies were also ruled out. Urinalysis detected benzodiazepines, cannabinoids, and opiates, and serological tests confirmed hepatitis C (genotype 1A by PCR). Cryoglobulinemia testing was negative.
CTA revealed embolic occlusions in the distal posterior tibial, peroneal, and anterior tibial arteries of the right foot, as well as in the left anterior tibial and peroneal arteries (Figure 1). A transthoracic echocardiogram (TTE) confirmed normal cardiac structure and function, with no evidence of thrombus, valvular disease, or a cardiac source of emboli. ALI was diagnosed, and IV heparin therapy was initiated.
CT angiography of the lower extremities reveals a right peroneal artery occlusion at the distal tibiofibular level. There is also a suspicion of distal emboli extending to the infra-popliteal arterial runoff vessels.
Subsequently, the patient reported improvements in his symptoms, particularly in his left foot. Upon examination, the left distal pulses were found to be biphasic when checked with a Doppler. However, the right dorsalis pedis pulse remained nonpalpable and undetectable via Doppler. Three percutaneous angioplasty procedures were performed to restore blood flow to his right leg, incorporating mechanical thrombectomy and pharmacologic thrombolysis. The attempts to revascularize his right foot were unsuccessful. After several days, the patient developed rhabdomyolysis, as indicated by an elevated CK level of 757 U/L. Given the circumstances, a decision was made to proceed with a below-knee amputation of the right leg. Pathology from the amputated foot showed no signs of Buerger’s disease.
The patient underwent surgery and experienced a good recovery. He is currently stable and undergoing physiotherapy to aid in his recovery and adaptation to the below-knee amputation. In addition, he is also receiving support for smoking cessation and counseling to address his previous anabolic steroid use. Regular follow-up appointments have been scheduled to monitor his recovery progress, manage any potential complications, and adjust his rehabilitation plan as needed. The patient has also been referred to a hepatologist for further management of his hepatitis C. Despite the challenges, the patient remains motivated and is making gradual improvements in his overall health and functional status.
Discussion
AAS are synthetic forms of natural testosterone. While they may promote muscle growth and enhance athletic performance, they pose significant health risks.1,8 Many countries have banned AAS due to the serious health hazards associated with them. 7
AAS affect the cardiovascular system in various ways. Among the testosterone formulations, short-acting intramuscular injections, such as testosterone cypionate and enanthate, exhibit the highest incidence of polycythemia, approaching 40%. 9 AAS cycles also increase the synthesis of coagulation factors. 10 Studies have demonstrated that AAS enhance platelet aggregation through the release of thromboxane A2 and other arachidonic acid products, findings supported by both human platelet-rich samples and animal models.11,12 Additionally, AAS can alter the lipid profile by raising low-density lipoprotein (LDL) and lowering high-density lipoprotein (HDL), potentially promoting dyslipidemia. There are several documented cases of vascular complications associated with AAS abuse, including myocardial infarction, stroke, renal artery thrombosis, and retinal artery occlusion.13-16
Prolonged AAS use has been associated with an increased risk of thrombosis and atherosclerosis, which can manifest as ALI. 17 Bodybuilders often display enhanced vascularity in their extremities, which can obscure early symptoms of thrombosis. 18 This increased vascularity may result in congested veins or blocked arteries, which can encourage the formation of collateral connections between arteries and veins.
Our patient exhibited classic signs and symptoms of ALI. Buerger’s disease was initially considered due to his smoking history but was ruled out based on pathology results. Cardiac sources of emboli and other secondary and inherited causes of thrombosis were also excluded. Given his young age, prolonged AAS use, and the exclusion of different causes, his ALI was most likely attributable to AAS use. Despite 3 attempts to restore blood flow to his right leg, the procedure was unsuccessful. The patient subsequently developed rhabdomyolysis, necessitating a below-knee amputation of the right leg. Even with early revascularization, the prognosis for ALI remains poor, with amputation rates of 10% to 15%. 19
A literature review from 1990 to 2024 identified 5 cases of ALI associated with AAS use.20-23 The locations of thrombosis, accompanying symptoms, and durations of AAS use varied among the cases. Of these, 3 involved unilateral ALI, while 2 were bilateral. These cases consistently involved young male athletes with no other identifiable causes for ALI, leaving AAS abuse as the most plausible factor. A detailed summary of these cases is provided in Table 1.
Summary of Reported Cases of Acute Lower Limb Ischemia Associated With Anabolic Androgenic Steroids Use. a
All patients reported were using androgens for bodybuilding.
AAS use is widespread among young athletes, mainly noncompetitive bodybuilders. According to a meta-analysis of 187 studies, the global lifetime prevalence of AAS use is 3.3%, with higher rates in men (6.4%) compared to women (1.6%). 24 Healthcare professionals must recognize the extent of this issue and the harmful impacts of AAS use. Increased efforts to educate young athletes about the dangers of AAS are crucial to mitigating these risks.
Conclusion
AAS use can result in disabling and potentially lethal side effects. While a direct link between AAS use and ALI has not been firmly established in the literature, extensive diagnostic workup and imaging in this case ruled out other causes, leaving AAS use as the primary predisposing factor. Healthcare professionals must actively engage with and educate the public, particularly young athletes, about the severe risks associated with AAS use.
Footnotes
Acknowledgements
We sincerely extend our thanks to the patient for his cooperation and assistance in publishing this case to raise awareness about AAS use among athletes. We also want to express our sincere appreciation to the Research Committee of the Internal Medicine Department at Marshall University, WV, for their invaluable support during the development of this manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics Approval
Our institution does not require ethical approval for reporting individual cases or case series.
Informed Consent
Verbal informed consent was obtained from the patient for their anonymized information to be published in this article.
Prior Submissions/Publications
This material has not been published in any meeting or journal.
